Nokea
A nurse plans to call the healthcare provider to report an 0600 serum potassium level of 2 mEq/L or mmol/L (SI), but the charge nurse tells the nurse that the healthcare provider does not like to receive early morning calls and will make rounds later in the morning. What action should the nurse take?
- A. Contact the healthcare provider immediately to report the laboratory value regardless of the advice.
- B. Document the finding and report it when the healthcare provider makes rounds.
- C. Notify the charge nurse that you are following the chain of command.
- D. Administer a potassium supplement and notify the provider later.
Correct Answer: A
Rationale: A nurse should contact the healthcare provider immediately to report a critically low potassium level of 2 mEq/L. Potassium levels below the normal range can lead to life-threatening complications such as cardiac arrhythmias. Prompt notification is essential to ensure timely intervention and prevent harm to the patient. Option B is incorrect as delaying reporting such a critical value can jeopardize patient safety. Option C is not the priority in this situation; the focus should be on patient care. Option D is dangerous and inappropriate as administering a potassium supplement without healthcare provider's guidance can be harmful, especially with a critically low level.
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The nurse is caring for a client with a history of myocardial infarction who is complaining of chest pain. Which intervention should the nurse implement first?
- A. Administer oxygen therapy as prescribed.
- B. Administer nitroglycerin sublingually as prescribed.
- C. Obtain an electrocardiogram (ECG).
- D. Assess the client's level of consciousness.
Correct Answer: C
Rationale: Obtaining an electrocardiogram (ECG) is the first priority in assessing for ischemia or infarction in a client with chest pain and a history of myocardial infarction. This diagnostic test provides crucial information about the heart's electrical activity and helps in identifying any acute cardiac changes. Administering oxygen therapy and nitroglycerin can be important interventions, but obtaining an ECG takes precedence as it directly assesses the client's cardiac status. Assessing the client's level of consciousness is also essential, but in this scenario, assessing for cardiac indications through an ECG is the initial step.
The nurse is caring for a client with a tracheostomy who has thick, tenacious secretions. Which assessment finding requires immediate intervention?
- A. Crepitus around the tracheostomy site
- B. Dry and cracked tracheostomy site
- C. Mucous plugging of the tracheostomy tube
- D. Yellowing of the skin around the tracheostomy site
Correct Answer: C
Rationale: Mucous plugging of the tracheostomy tube is the most concerning assessment finding in a client with a tracheostomy. It can lead to airway obstruction, which requires immediate intervention to ensure the client's airway remains patent. Crepitus around the tracheostomy site may indicate subcutaneous emphysema but is not as urgent as a blocked airway. A dry and cracked tracheostomy site may indicate poor skin integrity but does not pose an immediate threat to the client's airway. Yellowing of the skin around the tracheostomy site could suggest a localized infection, but it is not as critical as a potential airway obstruction caused by mucous plugging.
A male client is having abdominal pain after a left femoral angioplasty and stent, and is asking for additional pain medication for right lower quadrant pain (9/10). Two hours ago, he received hydrocodone/acetaminophen 7.5/7.50 mg. His vital signs are elevated from the previous hour: temperature 97.8 F, heart rate 102 beats per minute, respiration 20 breaths per minute. His abdomen is swollen, the groin access site is tender, peripheral pulses are present, but the left leg is larger than the right. Preoperatively, clopidogrel was prescribed for a history of previous peripheral stents. Another nurse is holding manual pressure on the femoral arterial access site which may be leaking into the abdomen. What data is needed to make this report complete?
- A. Client's lungs are clear bilaterally, and oxygen saturation is 97%.
- B. The surgeon needs to see the client immediately to evaluate the situation.
- C. Left peripheral pulses were present only by Doppler pre-procedure.
- D. Client's history includes multiple back surgeries and chronic pain.
Correct Answer: B
Rationale: The correct answer is B. Immediate evaluation by the surgeon is necessary due to the possibility of an internal hemorrhage, which is a life-threatening condition. Choice A is incorrect as lung status and oxygen saturation are not the priority in this situation. Choice C is not relevant to the current urgent issue. Choice D, while providing additional history, is not pertinent to the immediate concern of a potential internal hemorrhage post angioplasty and stent placement.
The nurse is preparing to administer an enema to a client with severe constipation. Which position is most appropriate for the client?
- A. Supine with the head elevated 30 degrees
- B. Left lateral with the right leg flexed
- C. Sims' position with the right leg flexed
- D. Prone position with the head turned to the side
Correct Answer: C
Rationale: Sims' position with the right leg flexed is the most appropriate position for administering an enema to a client with severe constipation. This position helps in promoting the flow of the enema solution into the rectum and facilitates the evacuation of stool. Supine position with the head elevated 30 degrees (Choice A) is not ideal for administering an enema as it does not facilitate the flow of the solution. Left lateral position with the right leg flexed (Choice B) is not the best choice for administering an enema. Prone position with the head turned to the side (Choice D) is also not suitable for administering an enema as it does not assist in the proper administration and retention of the solution.
A male client with cancer, who is receiving antineoplastic drugs, is admitted to the hospital. What findings are most often manifested in this condition?
- A. Ecchymosis and hematemesis
- B. Weight loss and alopecia
- C. Weakness and activity intolerance
- D. Sore throat and fever
Correct Answer: A
Rationale: The correct answer is A: Ecchymosis and hematemesis. These findings are often manifested in a client receiving antineoplastic drugs due to their potential side effects, including increased bleeding tendencies. Choice B, weight loss, and alopecia are more commonly associated with the side effects of cancer itself rather than antineoplastic drugs. Choice C, weakness, and activity intolerance can be seen in cancer patients but are not specific to antineoplastic drug therapy. Choice D, sore throat, and fever are less likely to be directly related to antineoplastic drugs and are more often linked to infections or other conditions.